Preliminary Experience with Virtual Monoenergetic Imaging and Iodine Mapping in the Primary Staging of Endometrial Cancer.

This study investigated whether virtual monoenergetic images (VMIs) and iodine mapping based on dual-energy CT (DECT) provide advantages in the assessment of endometrial cancer. A dual-source DECT was performed for primary staging of histologically proven endometrioid adenocarcinoma in 21 women (66.8 ± 12.0 years). In addition to iodine maps, VMIs at 40, 50, 60, 70, and 80 keV were reconstructed from polyenergetic images (PEIs). Objective analysis comprised the measurement of tumor contrast, contrast-to-noise ratio, and normalized iodine concentration (NIC). In addition, three radiologists independently rated tumor conspicuity. The highest tumor contrast (106.6 ± 45.0 HU) and contrast-to-noise ratio (4.4 ± 2.0) was established for VMIs at 40 keV. Tumor contrast in all VMIs ≤ 60 keV was higher than in PEIs (p < 0.001). The NIC of malignant tissue measured in iodine maps was substantially lower compared with a healthy myometrium (0.3 ± 0.1 versus 0.6 ± 0.1 mg/mL; p < 0.001). Tumor conspicuity was highest in 40 keV datasets, whereas no difference was found among PEIs and VMIs at 60 and 70 keV (p ≥ 0.334). Interobserver agreement was good, indicated by an intraclass correlation coefficient of 0.824 (0.772-0.876; p < 0.001). In conclusion, computation of VMIs at 40 keV and color-coded iodine maps aids the assessment of endometroid adenocarcinoma in primary staging.

Influence of spectral shaping and tube voltage modulation in ultralow-dose computed tomography of the abdomen.

PURPOSE: Unenhanced abdominal CT constitutes the diagnostic standard of care in suspected urolithiasis. Aiming to identify potential for radiation dose reduction in this frequent imaging task, this experimental study compares the effect of spectral shaping and tube voltage modulation on image quality. METHODS: Using a third-generation dual-source CT, eight cadaveric specimens were scanned with varying tube voltage settings with and without tin filter application (Sn 150, Sn 100, 120, 100, and 80 kVp) at three dose levels (3 mGy: standard; 1 mGy: low; 0.5 mGy: ultralow). Image quality was assessed quantitatively by calculation of signal-to-noise ratios (SNR) for various tissues (spleen, kidney, trabecular bone, fat) and subjectively by three independent radiologists based on a seven-point rating scale (7 = excellent; 1 = very poor). RESULTS: Irrespective of dose level, Sn 100 kVp resulted in the highest SNR of all tube voltage settings. In direct comparison to Sn 150 kVp, superior SNR was ascertained for spleen (p ≤ 0.004) and kidney tissue (p ≤ 0.009). In ultralow-dose scans, subjective image quality of Sn 100 kVp (median score 3; interquartile range 3-3) was higher compared with conventional imaging at 120 kVp (2; 2-2), 100 kVp (1; 1-2), and 80 kVp (1; 1-1) (all p < 0.001). Indicated by an intraclass correlation coefficient of 0.945 (95% confidence interval: 0.927-0.960), interrater reliability was excellent. CONCLUSIONS: In abdominal CT with maximised dose reduction, tin prefiltration at 100 kVp allows for superior image quality over Sn 150 kVp and conventional imaging without spectral shaping.

Recommendations of the German Radiological Society's breast imaging working group regarding breast MRI. / Aktualisierung der Empfehlungen der AG Mammadiagnostik der Deutschen Röntgengesellschaft zur Durchführung der Mamma-MRT.

· Breast MRI is an essential part of breast imaging. · The recommendations for performing breast MRI have been updated. · A table provides a compact and quick overview. More detailed comments supplement the table.. · The "classic" breast MRI can be performed based on the recommendations. Tips for special clinical questions, such as implant rupture, mammary duct pathology or local lymph node status, are included.. ZITIERWEISE: · Wenkel E, Wunderlich P, Fallenberg E et al. Aktualisierung der Empfehlungen der AG Mammadiagnostik der Deutschen Röntgengesellschaft zur Durchführung der Mamma-MRT. Fortschr Röntgenstr 2024; DOI: 10.1055/a-2216-0782.

Breast lesion morphology assessment with high and standard b values in diffusion-weighted imaging at 3 Tesla.

INTRODUCTION: With increasing spatial resolution, diffusion-weighted imaging (DWI) may be suitable for morphologic lesion characterization in breast MRI - an area that has traditionally been occupied by dynamic contrast-enhanced imaging (DCE). This investigation compared DWI with b values of 800 and 1600 s/mm2 to DCE for lesion morphology assessment in high-resolution breast MRI at 3 Tesla. MATERIAL AND METHODS: Multiparametric breast MRI was performed in 91 patients with 93 histopathologically proven lesions (31 benign, 62 malignant). Two radiologists independently evaluated three datasets per patient (DWIb800; DWIb1600; DCE) and assessed lesion visibility and BIRADS morphology criteria. Diagnostic accuracy was compared among readers and datasets using Cochran's Q test and pairwise post-hoc McNemar tests. Bland-Altman analyses were conducted for lesion size comparisons. RESULTS: Discrimination of carcinomas was superior compared to benign findings in both DWIb800 and DWIb1600 (p < 0.001) with no b value-dependent difference. Similarly, assessability of mass lesions was better than of non-mass lesions, irrespective of b value (p < 0.001). Intra-reader reliability for the analysis of morphologic BIRADS criteria among DCE and DWI datasets was at least moderate (Fleiss κ≥0.557), while at least substantial inter-reader agreement was ascertained over all assessed categories (κ≥0.776). In pairwise Bland-Altman analyses, the measurement bias between DCE and DWIb800 was 0.7 mm, whereas the difference between DCE and DWIb1600 was 2.8 mm. DWIb1600 allowed for higher specificity than DCE (p = 0.007/0.062). CONCLUSIONS: DWI can be employed for reliable morphologic lesion characterization in high-resolution breast MRI. High b values increase diagnostic specificity, while lesion size assessment is more precise with standard 800 s/mm2 images.

Deep Learning k-Space-to-Image Reconstruction Facilitates High Spatial Resolution and Scan Time Reduction in Diffusion-Weighted Imaging Breast MRI.

BACKGROUND: For time-consuming diffusion-weighted imaging (DWI) of the breast, deep learning-based imaging acceleration appears particularly promising. PURPOSE: To investigate a combined k-space-to-image reconstruction approach for scan time reduction and improved spatial resolution in breast DWI. STUDY TYPE: Retrospective. POPULATION: 133 women (age 49.7 ± 12.1 years) underwent multiparametric breast MRI. FIELD STRENGTH/SEQUENCE: 3.0T/T2 turbo spin echo, T1 3D gradient echo, DWI (800 and 1600 sec/mm2 ). ASSESSMENT: DWI data were retrospectively processed using deep learning-based k-space-to-image reconstruction (DL-DWI) and an additional super-resolution algorithm (SRDL-DWI). In addition to signal-to-noise ratio and apparent diffusion coefficient (ADC) comparisons among standard, DL- and SRDL-DWI, a range of quantitative similarity (e.g., structural similarity index [SSIM]) and error metrics (e.g., normalized root mean square error [NRMSE], symmetric mean absolute percent error [SMAPE], log accuracy error [LOGAC]) was calculated to analyze structural variations. Subjective image evaluation was performed independently by three radiologists on a seven-point rating scale. STATISTICAL TESTS: Friedman's rank-based analysis of variance with Bonferroni-corrected pairwise post-hoc tests. P < 0.05 was considered significant. RESULTS: Both DL- and SRDL-DWI allowed for a 39% reduction in simulated scan time over standard DWI (5 vs. 3 minutes). The highest image quality ratings were assigned to SRDL-DWI with good interreader agreement (ICC 0.834; 95% confidence interval 0.818-0.848). Irrespective of b-value, both standard and DL-DWI produced superior SNR compared to SRDL-DWI. ADC values were slightly higher in SRDL-DWI (+0.5%) and DL-DWI (+3.4%) than in standard DWI. Structural similarity was excellent between DL-/SRDL-DWI and standard DWI for either b value (SSIM ≥ 0.86). Calculation of error metrics (NRMSE ≤ 0.05, SMAPE ≤ 0.02, and LOGAC ≤ 0.04) supported the assumption of low voxel-wise error. DATA CONCLUSION: Deep learning-based k-space-to-image reconstruction reduces simulated scan time of breast DWI by 39% without influencing structural similarity. Additionally, super-resolution interpolation allows for substantial improvement of subjective image quality. EVIDENCE LEVEL: 4 TECHNICAL EFFICACY: Stage 1.

Whitepaper: Training in Diagnostic and Interventional Breast Radiology. / Whitepaper: Weiterbildung in der bildgebenden und interventionellen Mammadiagnostik.

PURPOSE: Breast imaging represents an integral part of radiology and is subject to strict quality controls. Regarding this, precise diagnostics including multimodal assessment by mammography, sonography, and MRI, including image-guided biopsy and localization procedures, is often decisive and must be performed by experts with profound knowledge and skills in all of these procedures.However, due to numerous restructurings, breast imaging has been shifted more and more towards large, specialized centers, resulting in less patient exposition and training opportunities for radiologists in smaller sites. The following whitepaper summarizes the current circumstances and discusses opinions of the participating societies. MATERIALS: Under the leadership of the German Roentgen Society (DRG) and with the participation of the DRG's AG Mammadiagnostik, the CAFRAD (Chefarztforum Radiologie), the KLR (Konferenz der Lehrstuhlinhaber für Radiologie e. V.), the DRG's Forum Junge Radiologie (FJR) and the Berufsverband der Deutschen Radiologen e. V. (BDR), possible solutions were discussed and consented for a structured training in breast radiology in the future. RESULTS: In addition to the teaching provided at the primary workplace, qualified training should be ensured through flexible, multi-institutional, interdisciplinary, and cross-sectoral collaboration. Furthermore, the integration of online case collections and close cooperation with certified breast cancer centers and mammography screening units is recommended. It is indispensible that online courses and case collections adhere to the standards of the national societies and include a maximum of one third of the required cases. CONCLUSION: In order to provide training in breast radiology at a high professional level, a paradigm shift with closer cooperation of all participants is necessary. This includes close collaboration of the breast imaging societies with the federal medical associations to establish new teaching concepts like e-learning in the training schedule of radiologists. KEY POINTS: · Breast diagnostics is an integral part of radiology training.. · Due to recent restructurings, smaller training centers have difficulties in meeting the case numbers demanded by the Specialist Training Regulations (WBO). Improved integration of the new structures and their adaptation to the needs of education are necessary to guarantee standardized high-quality training of young radiologists.. · The integration of certified case collections enables quality-assured training, even across regions in online-based formats. In accordance with the "blended learning principle", up to one-third of the required number of patient studies can be substituted with cases from a certified case collection.. · Legally secured short- and medium-term internships may complement training in radiology.. CITATION FORMAT: · Sauer ST, Bley TA, Wenkel E et al. Whitepaper: Training in Diagnostic and Interventional Breast Radiology. Fortschr Röntgenstr 2023; 195: 699 - 706.

Obesity-Related Pitfalls of Virtual versus True Non-Contrast Imaging-An Intraindividual Comparison in 253 Oncologic Patients.

OBJECTIVES: Dual-source dual-energy CT (DECT) facilitates reconstruction of virtual non-contrast images from contrast-enhanced scans within a limited field of view. This study evaluates the replacement of true non-contrast acquisition with virtual non-contrast reconstructions and investigates the limitations of dual-source DECT in obese patients. MATERIALS AND METHODS: A total of 253 oncologic patients (153 women; age 64.5 ± 16.2 years; BMI 26.6 ± 5.1 kg/m2) received both multi-phase single-energy CT (SECT) and DECT in sequential staging examinations with a third-generation dual-source scanner. Patients were allocated to one of three BMI clusters: non-obese: <25 kg/m2 (n = 110), pre-obese: 25-29.9 kg/m2 (n = 73), and obese: >30 kg/m2 (n = 70). Radiation dose and image quality were compared for each scan. DECT examinations were evaluated regarding liver coverage within the dual-energy field of view. RESULTS: While arterial contrast phases in DECT were associated with a higher CTDIvol than in SECT (11.1 vs. 8.1 mGy; p < 0.001), replacement of true with virtual non-contrast imaging resulted in a considerably lower overall dose-length product (312.6 vs. 475.3 mGy·cm; p < 0.001). The proportion of DLP variance predictable from patient BMI was substantial in DECT (R2 = 0.738) and SECT (R2 = 0.620); however, DLP of SECT showed a stronger increase in obese patients (p < 0.001). Incomplete coverage of the liver within the dual-energy field of view was most common in the obese subgroup (17.1%) compared with non-obese (0%) and pre-obese patients (4.1%). CONCLUSION: DECT facilitates a 30.8% dose reduction over SECT in abdominal oncologic staging examinations. Employing dual-source scanner architecture, the risk for incomplete liver coverage increases in obese patients.

Automation Bias in Mammography: The Impact of Artificial Intelligence BI-RADS Suggestions on Reader Performance.

Background Automation bias (the propensity for humans to favor suggestions from automated decision-making systems) is a known source of error in human-machine interactions, but its implications regarding artificial intelligence (AI)-aided mammography reading are unknown. Purpose To determine how automation bias can affect inexperienced, moderately experienced, and very experienced radiologists when reading mammograms with the aid of an artificial intelligence (AI) system. Materials and Methods In this prospective experiment, 27 radiologists read 50 mammograms and provided their Breast Imaging Reporting and Data System (BI-RADS) assessment assisted by a purported AI system. Mammograms were obtained between January 2017 and December 2019 and were presented in two randomized sets. The first was a training set of 10 mammograms, with the correct BI-RADS category suggested by the AI system. The second was a set of 40 mammograms in which an incorrect BI-RADS category was suggested for 12 mammograms. Reader performance, degree of bias in BI-RADS scoring, perceived accuracy of the AI system, and reader confidence in their own BI-RADS ratings were assessed using analysis of variance (ANOVA) and repeated-measures ANOVA followed by post hoc tests and Kruskal-Wallis tests followed by the Dunn post hoc test. Results The percentage of correctly rated mammograms by inexperienced (mean, 79.7% ± 11.7 [SD] vs 19.8% ± 14.0; P < .001; r = 0.93), moderately experienced (mean, 81.3% ± 10.1 vs 24.8% ± 11.6; P < .001; r = 0.96), and very experienced (mean, 82.3% ± 4.2 vs 45.5% ± 9.1; P = .003; r = 0.97) radiologists was significantly impacted by the correctness of the AI prediction of BI-RADS category. Inexperienced radiologists were significantly more likely to follow the suggestions of the purported AI when it incorrectly suggested a higher BI-RADS category than the actual ground truth compared with both moderately (mean degree of bias, 4.0 ± 1.8 vs 2.4 ± 1.5; P = .044; r = 0.46) and very (mean degree of bias, 4.0 ± 1.8 vs 1.2 ± 0.8; P = .009; r = 0.65) experienced readers. Conclusion The results show that inexperienced, moderately experienced, and very experienced radiologists reading mammograms are prone to automation bias when being supported by an AI-based system. This and other effects of human and machine interaction must be considered to ensure safe deployment and accurate diagnostic performance when combining human readers and AI. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Baltzer in this issue.

Artificial-intelligence-enhanced synthetic thick slabs versus standard slices in digital breast tomosynthesis.

OBJECTIVES: Digital breast tomosynthesis (DBT) can provide additional information over mammography, albeit at the cost of prolonged reading time. This study retrospectively investigated the impact of reading enhanced synthetic 6 mm slabs instead of standard 1 mm slices on interpretation time and readers performance in a diagnostic assessment centre. METHODS: Three radiologists (R1-3; 6/4/2 years of breast imaging experience) reviewed 111 diagnostic DBT examinations. Two datasets were interpreted independently for each patient, with one set containing artificial-intelligence-enhanced synthetic 6 mm slabs with 3 mm overlap, while the other set comprised standard 1 mm slices. Blinded to histology and follow-up, readers noted individual BIRADS categories and diagnostic confidence while reading time was recorded. Among the 111 examinations, 70 findings were histopathologically correlated including 56 malignancies. RESULTS: No significant difference was found between BIRADS categories assigned based on 6 mm vs 1 mm datasets (p ≥ 0.317). Diagnostic accuracy was comparable for 6 mm and 1 mm readings (R1: 87.0% vs 87.0%; R2: 86.1% vs 87.0%; R3: 80.0% vs 84.4%; p ≥ 0.125) with high interrater agreement (intraclass correlation coefficient 0.848 vs 0.865). One reader reported higher confidence with 1 mm slices (R1: p = 0.033). Reading time was substantially shorter when interpreting 6 mm slabs compared to 1 mm slices (R1: 33.5 vs 46.2; R2: 49.1 vs 64.8; R3: 39.5 vs 67.2 sec; all p < 0.001). CONCLUSIONS: Artificial-intelligence-enhanced synthetic 6 mm slabs allow for substantial interpretation time reduction in diagnostic DBT without a decrease in reader accuracy. ADVANCES IN KNOWLEDGE: A simplified slab-only protocol instead of 1 mm slices may offset the higher reading time without a loss of diagnosis-relevant image information in first and second readings. Further evaluations are required regarding workflow implications, particularly in screening settings.

Potential of Unenhanced Ultra-Low-Dose Abdominal Photon-Counting CT with Tin Filtration: A Cadaveric Study.

OBJECTIVES: This study investigated the feasibility and image quality of ultra-low-dose unenhanced abdominal CT using photon-counting detector technology and tin prefiltration. MATERIALS AND METHODS: Employing a first-generation photon-counting CT scanner, eight cadaveric specimens were examined both with tin prefiltration (Sn 100 kVp) and polychromatic (120 kVp) scan protocols matched for radiation dose at three different levels: standard-dose (3 mGy), low-dose (1 mGy) and ultra-low-dose (0.5 mGy). Image quality was evaluated quantitatively by means of contrast-to-noise-ratios (CNR) with regions of interest placed in the renal cortex and subcutaneous fat. Additionally, three independent radiologists performed subjective evaluation of image quality. The intraclass correlation coefficient was calculated as a measure of interrater reliability. RESULTS: Irrespective of scan mode, CNR in the renal cortex decreased with lower radiation dose. Despite similar mean energy of the applied x-ray spectrum, CNR was superior for Sn 100 kVp over 120 kVp at standard-dose (17.75 ± 3.51 vs. 14.13 ± 4.02), low-dose (13.99 ± 2.6 vs. 10.68 ± 2.17) and ultra-low-dose levels (8.88 ± 2.01 vs. 11.06 ± 1.74) (all p ≤ 0.05). Subjective image quality was highest for both standard-dose protocols (score 5; interquartile range 5-5). While no difference was ascertained between Sn 100 kVp and 120 kVp examinations at standard and low-dose levels, the subjective image quality of tin-filtered scans was superior to 120 kVp with ultra-low radiation dose (p < 0.05). An intraclass correlation coefficient of 0.844 (95% confidence interval 0.763-0.906; p < 0.001) indicated good interrater reliability. CONCLUSIONS: Photon-counting detector CT permits excellent image quality in unenhanced abdominal CT with very low radiation dose. Employment of tin prefiltration at 100 kVp instead of polychromatic imaging at 120 kVp increases the image quality even further in the ultra-low-dose range of 0.5 mGy.

Diffusion-weighted Breast MRI at 3 Tesla: Improved Lesion Visibility and Image Quality with a Combination of Water-excitation and Spectral Fat Saturation.

RATIONALE AND OBJECTIVES: In breast MRI with diffusion-weighted imaging (DWI), fat suppression is essential for eliminating the dominant lipid signal. This investigation evaluates a combined water-excitation-spectral-fatsat method (WEXfs) versus standard spectral attenuated inversion recovery (SPAIR) in high-resolution 3-Tesla breast MRI. MATERIALS AND METHODS: Multiparametric breast MRI with 2 echo-planar DWI sequences was performed in 83 patients (50.1 ± 12.6 years) employing either WEXfs or SPAIR for fat signal suppression. Three radiologists assessed overall DWI quality and delineability of 88 focal lesions (28 malignant, 60 benign) on images with b values of 800 and 1600 s/mm2, as well as apparent diffusion coefficient (ADC) maps. For each fat suppression method and b value, the longest lesion diameter was determined in addition to measuring the signal intensity in DWI and ADC value in standardized regions of interest. RESULTS: Regardless of b values, image quality (all p < 0.001) and lesion delineability (all p ≤ 0.003) with WEXfs-DWI were deemed superior compared to SPAIR-DWI in benign and malignant lesions. Irrespective of lesion characterization, WEXfs-DWI provided superior signal-to-noise, contrast-to-noise and signal-intensity ratios with 1600 s/mm2 (all p ≤ 0.05). The lesion size difference between contrast-enhanced T1 subtraction images and DWI was smaller for WEXfs compared to SPAIR fat suppression (all p ≤ 0.007). The mean ADC value in malignant lesions was lower for WEXfs-DWI (p < 0.001), while no significant ADC difference was ascertained between both techniques in benign lesions (p = 0.947). CONCLUSION: WEXfs-DWI provides better subjective and objective image quality than standard SPAIR-DWI, resulting in a more accurate estimation of benign and malignant lesion size.

Evaluation of different imaging modalities for axillary lymph node staging in breast cancer patients to provide a personalized and optimized therapy algorithm.

PURPOSE: The reliable detection of tumor-infiltrated axillary lymph nodes for breast cancer [BC] patients plays a decisive role in further therapy. We aimed to find out whether cross-sectional imaging techniques could improve sensitivity for pretherapeutic axillary staging in nodal-positive BC patients compared to conventional imaging such as mammography and sonography. METHODS: Data for breast cancer patients with tumor-infiltrated axillary lymph nodes having received surgery between 2014 and 2020 were included in this study. All examinations (sonography, mammography, computed tomography [CT] and magnetic resonance imaging [MRI]) were interpreted by board-certified specialists in radiology. The sensitivity of different imaging modalities was calculated, and binary logistic regression analyses were performed to detect variables influencing the detection of positive lymph nodes. RESULTS: All included 382 breast cancer patients had received conventional imaging, while 52.61% of the patients had received cross-sectional imaging. The sensitivity of the combination of all imaging modalities was 68.89%. The combination of MRI and CT showed 63.83% and the combination of sonography and mammography showed 36.11% sensitivity. CONCLUSION: We could demonstrate that cross-sectional imaging can improve the sensitivity of the detection of tumor-infiltrated axillary lymph nodes in breast cancer patients. Only the safe detection of these lymph nodes at the time of diagnosis enables the evaluation of the response to neoadjuvant therapy, thereby allowing access to prognosis and improving new post-neoadjuvant therapies.

Tin-filtered 100 kV Ultra-low-dose Abdominal CT for Calculi Detection in the Urinary Tract: A Comparative Study of 510 Cases.

OBJECTIVES: For detection of urinary calculi, unenhanced low-dose computed tomography is the method of choice, outperforming radiography and ultrasound. This retrospective monocentric study aims to compare a clinically established, dedicated low-dose imaging protocol for detection of urinary calculi with an ultra-low-dose protocol employing tin prefiltration at a standardized tube voltage of 100 kVp. METHODS: Two study arms included a total of 510 cases. The "low-dose group" was comprised of 290 individuals (96 women; age 49 ± 16 years; BMI 27.23 ± 5.60 kg/m2). The "ultra-low-dose group" with Sn100 kVp consisted of 220 patients (84 women; age 47 ± 17 years; BMI 26.82 ± 5.62 kg/m2). No significant difference was ascertained for comparison of age (p = 0.132) and BMI (p = 0.207) between cohorts. For quantitative assessment of image quality, image noise was assessed. RESULTS: No significant difference regarding frequency of calculi detection was found between groups (p = 0.596). Compared to the low-dose protocol (3.08 mSv; IQR 2.22-4.02 mSv), effective dose was reduced by 62.35% with the ultra-low-dose protocol employing spectral shaping (1.16 mSv; IQR 0.89-1.54 mSv). Image noise was calculated at 18.90 (IQR 17.39-21.20) for the low-dose protocol and at 18.69 (IQR 17.30-21.62) for the ultra-low-dose spectral shaping protocol. No significant difference was ascertained for comparison between groups (p = 0.793). CONCLUSION: For urinary calculi detection, ultra-low-dose scans utilizing spectral shaping by means of tin prefiltration at 100 kVp allow for considerable dose reduction of up to 62% over conventional low-dose CT without compromising image quality.

Prepubertal Idiopathic Unilateral Gynecomastia: Case Report and Literature Review.

Introduction: Gynecomastia is a benign proliferation of the glandular tissue of the breast in males. Depending on the age, it can be considered a physiological condition. Prepubertal unilateral gynecomastia is a rare phenomenon. There are only a few case reports described through the last few years. Case Presentation: We report the clinical appearance and management of prepubertal idiopathic unilateral gynecomastia in a 9-year-old boy. We further include a literature review of 14 cases from 2011 to 2021. In contrast to pubertal gynecomastia, prepubertal gynecomastia and especially unilateral prepubertal gynecomastia are extremely rare conditions. Most cases remain idiopathic. Conclusion: Chromosomal and genetic testing, as well as oncological, endocrine diagnostic and tests for liver and kidney function should be performed. In case of idiopathic prepubertal gynecomastia, surgery is an important part of therapy since patients suffer from their atypical and rare phenotype.

Total Mesometrial Resection With (Neo)Adjuvant Chemotherapy in Locally Advanced Cervical Cancer: A Tumor Response Score.

BACKGROUND/AIM: There is a lack of data concerning the surgical treatment of locally advanced squamous cell carcinoma of the uterine cervix (LACC) with neoadjuvant and adjuvant chemotherapy (NACT, ACT) as well as total mesometrial resection (TMMR). The aim of the study was to present a novel approach for treating LACC using a tumor response score for NACT. PATIENTS AND METHODS: A total of 12 patients with LACC were treated with NACT [cisplatin, ifosfamide, paclitaxel (TIP)], TMMR and ACT containing TIP. To measure the response during NACT, we scored i) the maximum tumor diameter (maxTD) in gynecological examination, ii) the MRI for radiologic maxTD, iii) the tumor volume and iv) the squamous cell carcinoma antigen before and after two applications of TIP. RESULTS: TIP reduced all score-parameters in 10 of 12 patients (p<0.005). We found a possible reduction of lymph node metastasis in 72.7%. The proposed score detected sufficient and insufficient tumor response. CONCLUSION: TIP followed by TMMR with ACT could be a possibility for patients denying radiochemotherapy. The tumor response score can detect patients with inadequate benefit from NACT.

How to increase the attractiveness of undergraduate rural clerkships? A cross-sectional study among medical students at two German medical schools.

OBJECTIVES: While literature provides substantial evidence that undergraduate rural clerkships may contribute to attract medical students to rural careers, so far little is known about how to convince medical students to choose rural teaching sites for their clerkships, which is usually optional. Thus, this study aimed to investigate students' preferences and perceptions regarding different rural teaching and clerkship formats, important side conditions and suitable communication strategies to promote rural clerkships. DESIGN: Cross-sectional study based on a quantitative survey among medical students in advanced study years. SETTING: Two German medical schools (Leipzig and Halle-Wittenberg). PARTICIPANTS: Medical students in third to fifth year (of six). RESULTS: Response rate was 87.1% with n=909 analysable questionnaires. Participants' mean age was 25.0 years and 65.2% were women. For 97.9% of the students completing some kind of rural clerkship was imaginable, for 90.8% even participation in a rural clerkship of 4 weeks and longer. Nearly half of the students (48.0%) specified that a rural clerkship 4 weeks and longer was 'absolutely imaginable'. Younger age, having grown up in a rural or small-town region, being able to imagine future working in a small-town or rural area, and general practice as favoured, or at least conceivable career option were independently associated with a higher willingness to complete longer rural clerkships. Financial and organisational issues including remuneration of the clerkship, cost absorption for travelling and accommodation, and accessibility by public transport were the most important side conditions to increase the attractiveness of rural clerkships. Experience reports by fellow students, social media and informational events were stated to be the most suitable ways to advertise rural teaching offers. CONCLUSIONS: The majority of the students are open-minded regarding even longer rural clerkships. This study adds new insights into measures that should be taken to convince them to actually chose this option.

High-risk breast cancer surveillance with MRI: 10-year experience from the German consortium for hereditary breast and ovarian cancer.

PURPOSE: To report on 10 years of high-risk service screening with annual MRI in the German Consortium for Hereditary Breast and Ovarian Cancer (GC-HBOC). METHODS: A cohort of 4,573 high-risk, previously unaffected women (954 BRCA1 carriers, 598 BRCA2 carriers, 3021 BRCA1/2 non-carriers) participating in the GC-HBOC surveillance program was prospectively followed. Screening outcomes for 14,142 screening rounds with MRI between 2006 and 2015 were analyzed and stratified by risk group, type of screening round, and age. RESULTS: A total of 221 primary breast cancers (185 invasive, 36 in situ) were diagnosed within 12 months of an annual screening round with MRI. Of all cancers, 84.5% (174/206, 15 unknown) were stage 0 or I. In BRCA1 carriers, 16.9% (10/59, 5 unknown) of all incident cancers (screen-detected and interval cancers combined) and in BRCA2 carriers 12.5% (3/24, 4 unknown) were stage IIA or higher, compared to only 4.8% (2/42, 2 unknown) in high-risk BRCA1/2 non-carriers. Program sensitivity was 89.6% (95% CI 84.9-93.0) with no significant differences in sensitivity between risk groups or by age. Specificity was significantly lower in the first screening round (84.6%, 95% CI 83.6-85.7) than in subsequent screening rounds (91.1%, 95% CI 90.6-91.7), p < 0.001. Cancer detection rates (CDRs) and as a result positive predictive values were strongly dependent on type of screening round, risk group and patient age. CDRs ranged from 43.5‰ (95% CI 29.8-62.9) for the first screening round in BRCA2 carriers to 2.9‰ (95% CI 1.3-6.3) for subsequent screening rounds in high-risk non-carriers in the age group 30 to 39 years. CONCLUSIONS: High-risk screening with MRI was successfully implemented in the GC-HBOC with high sensitivity and specificity. Risk prediction and inclusion criteria in high-risk non-carriers need to be adjusted to improve CDRs and thus screening efficacy in these patients.

Partial segmental thrombosis of the corpus cavernosum (PSTCC) diagnosed by contrast-enhanced ultrasound: a case report.

BACKGROUND: Partial segmental thrombosis of the corpus cavernosum (PSTCC) is a rare disease predominantly occurring in young men. Cardinal symptoms are pain and perineal swelling. Although several risk factors are described in the literature, the exact etiology of penile thrombosis remains unclear in most cases. MRI or ultrasound (US) is usually used for diagnosing this condition. CASE PRESENTATION: We report a case of penile thrombosis after left-sided varicocele ligature in a young patient. The diagnosis was established using contrast-enhanced ultrasound (CEUS) and was confirmed by contrast-enhanced magnetic resonance imaging (ceMRI). Successful conservative treatment consisted of systemic anticoagulation using low molecular weight heparin and acetylsalicylic acid. CONCLUSION: PSTCC is a rare condition in young men and appears with massive pain and perineal swelling. In case of suspected PSTCC utilization of CEUS may be of diagnostic benefit.